This form is designed to help us safely and effectively dispense your medicine. Please answer truthfully.

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I have never heard of it before
Not more than six months ago
More than six months ago.








Male
Female
Transmale (Born a female)
Transfemale (Born a male)

Presently Pregnant
Presently Breastfeeding
Planning on getting pregnant
Planning on Becoming Pregnant
Neither Pregnant nor Breastfeeding




I have never heard of it before
Not more than six months ago
More than six months ago.







After an examination by a certified doctor or a Sexual Health Clinic's diagnosis
You tested positive after a Chlamydia examination
Your sexual partner shared his awareness of the condition with you
You have undergone self examination


















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